For Blue Cross’ PPO (commercial), Medicare Plus BlueSM PPO, BCN HMOSM (commercial) and BCN AdvantageSM requests. M. ay 2020. 1. Check the category that applies to your request: For non-behavioral health facility inpatient admissions for all plans: Check one (below), then complete the form and fax it to 1-866-373-9468 or email it to ...
Type of request (select one): PCP Referral to Specialist – only complete sections 2 through 5 on page 1 of this form. SAVE and FAX to 1 (844) 263-2272. Precertification Request – all of the following information and documentation is required. Incomplete forms will be returned for additional information. SAVE and FAX to 1 (844) 263-2272. a.
Appeal Forms. Provider Reconsideration Form; Provider Appeal Form; Provider Appeal – Expedited; Value Based Payment Appeal Form; Value Based Reconsideration Form; Patient Authorizations – Forms you send us to approve care for a patient. Ventilator Weaning and Sub-Acute Tracheal Suctioning Request; Chiropractic Treatment Request Form
Blue Cross and Blue Shield of Louisiana and its subsidiaries, HMO Louisiana, Inc. and Southern National Life Insurance Company, Inc., comply with applicable federal civil rights laws and do not exclude people or treat them differently on the basis of race, color, national origin, age, disability or sex.
How to form an LLC in Georgia (Step-by-step instructions). Search your Georgia LLC name. A Georgia LLC can be used to operate a business, or an LLC can be used to acquire and hold assets (such as real estate, vehicles, boats, or aircraft).
The appeal must be received by Anthem Blue Cross (Anthem) within 365 days from the date on the notice of the letter advising of the action. Anthem uses Availity, a secure, full-service web portal that offers a claims clearinghouse and real-time transactions at no charge to health care professionals.
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